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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.. Job Address ) 3-SS ( S ` �Q`yn�I u FA City (�txLot Size PM Owner's Name AOOCL �� 5 Address LAZA I11� Phone OW Q� Address -� � Contractor / f (�, License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 N TYPE OF SEPTIC WORK: NEW INSTALLATION W REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is V� available within 200 feet.) f Installation will serve: Residence— Commercial— Other t2 H b Number of living units:/ Number of bedrooms _�) _ Character of soil to a depth of 3 feet: .5 Water table depth LA SEPTIC TANK ®--Type/Mfg 1 Capacity �2 No. Compartments Z PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ,�T Foundation Jy Property Line 100 LEACHING LINE El--No. & Length of lines c&- 7(i Total length/size (910 ' FILTER BED ❑ Distance to nearest: Well UO t Foundation ly Property Line /00 3 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 70 DISPOSAL PONDS ❑ SY I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, andr rules and regulations of the San Joaquin Local Health District. ' Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applican t call for requir d ins pec'o S. Complete drawing on(,reverse side. Signe 11 Title: jQ Date: FO DEPARTMENT USE ONLY U Date 3-, -) Area = 06 Application Accepted b Pit or Grout Inspection by Date Final Inspection by j £�� - Date = ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.1/8 5) INFO EH 14.28 -� • �'4 I '" I / i ��